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OWNER NAME / ' I l PH(N�E C! OWNER ADDRES:: Pr aF ! CFfY/STATF./ZIP Q CONTRACTOR N. AV bA) 1 C-I+ q CONTRACTORADDRFS` I CITYJSfATC/LIP LJ r SUBCONTRACTOR PtiONE SUBCONTRACTORADDRESS - CITY/STATFJZIP LICENSE O C-57 ❑C-6! ❑D•09 Other AZZO NUM13C-R &=&, 7=EXPIRATION DAT GEOGRAPHICAL INFORMATION: Coordinates X Y Township Rringe Section INTENDED USE Domestic/Private ❑Irrigatioa'Agricultural ❑Industrial O Water Quality Monitoring 0 Soil SamplingK_haracterilation ❑Public Water Sr.ten; _ IfdifrerentfromOwner.r yIFCMName — .mmo wznwur Phone Run r TYPE OF WORK ❑New Well ❑Replvcmcnt Well O Well Alteration/Modification O Test Hole CO Other ❑Monitoring Well(s) d of wells ❑Soil Boring(s) _ 0ofbonng` 0 Ciontechnical borbonnp ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Seryicc Well Renewal O New Pump '�16utrp Replaxment ❑Pump Repair ❑Cro>s-Connuclion Ra air WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rnuiry ❑Auger O Cable Toot ❑Push Point O Other _ Proposed Well Depth_ _ R Excavation __in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sire_ in diameter ❑Conductor Casing in diatt:eter I Conductor Casing Depth fl Well Citing Diameter in Thickness�Gauge/ASIA Sched_ D Steel ❑Nasuc ❑Stainless Steel O Other Grout Seal Depth --ft ❑!teat Cement(4I Jh hag/S-/0 gal water) O Sand Cement sack mix 17 gal water O Bentonite(20%solids) ❑.Manufacturer Spic%solids_ % Name _ ❑Specs On rile O Specs Submitted C Grout Placement Method ❑Pumped O Free Fall ❑tither_ ❑RcArdani i Accelerator(name) PEDF_STAL Installed By O Driller ❑Pump Contractor O Other _ ❑Concrete Pedestal Dimensions: Width _ A length ft Thick in ❑Christy Boa O Stove Pipe v PUMP Submersible O Turbine ❑Othcr HP Pump Set ft Standing Water Level R 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND T"AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MV REQUIRED LICENSE 1S CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI 24 HOUR VANCE NOT IC IRE INSPECTIONS (' SIGNSdZ�14� TITLs Z649f42DATE r D51 ILn` Z 10 IL EL t DEPARTMENT USE ONLY IX9 p Application Accepted By �--- _ D-dte___r42-7 C c Area Z f'6 Umpktyw IDI# 119"7G Grout Inspection By Date 0 SPECIAL Well Permit Pump Inspection By Bate D WAIVER Received Destruction Inspac:tion By Date Coastrvcted Well Deptb it COMMENTS